Abstract
This aricle is inspired by the need to respond to recurrent criicisms regarding the lack of operability of bioethics. It presents and characterizes three approaches that have tried to answer this criicism: principlism, casuistry and narraive. It also discusses the characterizaion of these approaches, especially in terms of the concepts of bioethics they defend. The aricle concludes by discussing the importance of carrying out a criique of such approaches, aimed at providing an alternaive theory that responds to a broader concept of bioethics, as defended by the bioethics that has emerged from peripheral countries.
Keywords: Bioethics. Principle-based ethics. Bioethics-Case studies. Bioethics-Narraion.
Resumo
Três apostas por uma bioéica práica
Este arigo vem da necessidade de responder as recorrentes críicas feitas à bioéica sobre a sua falta de operabilidade. Também apresenta e caracteriza três abordagens que tentaram respondê-las: principialismo, casuísica e narraiva. Além disso, discute a caracterização dessas abordagens, especialmente no que diz respeito ao conceito de bioéica que defendem, e de igual modo, inaliza indicando a importância da realização de uma críica dessas abordagens citadas acima, com o intuito de oferecer futuramente, uma alternaiva que responda a um conceito amplo de bioéica como defendido pela bioéica nascida em países periféricos.
Palavras-chave: Bioéica. Éica baseada em princípios. Bioéica-Estudos de casos. Bioéica-Narração.
Resumen
Tres apuestas por una bioéica prácica
Este arículo nace de la necesidad de responder a la recurrente críica que se hace a la bioéica, sobre su falta de operaividad. Presenta y caracteriza los tres enfoques que han tratado de responder esta críica: principialismo, casuísica y narraiva. Discute la caracterización hecha de esos enfoques, especialmente en lo relaivo al concepto de bioéica que deienden. Finaliza, señalando la importancia de emprender una críica a los citados enfoques, en el intento de ofrecer futuramente uno alternaivo que responda a un concepto de bioéica amplio, como el defendido por las bioéicas nacidas en los países periféricos.
Palabras claves: Bioéica. Éica basada en principios. Bioéica-Estudios de casos. Bioéica-Narración.
Doutorando camilomanchola@gmail.com – Universidade de Brasília (UnB), Brasília/DF, Brasil.
Correspondência
Camilo Manchola – Campus Universitário Darcy Ribeiro, Faculdade de Ciências da Saúde, Programa de Pós-Graduação em Bioéica Caixa postal: 04451 CEP 70910-900. Brasília/DF, Brasil.
Declara não haver conlitos de interesse.
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Bioethics is about to turn 50, and although it remains in the iniial process of consolidaion, faces several recurring criicisms. Regardless of whether one considers the biomedical and biotechnological bioethics advocated by Beauchamp and Childress 1 or the more comprehensive global bioethics proposed by Poter 2, one of the most important
criicisms remains the same: bioethics does not respond adequately to the “pracical”, an issue which arises from its concepion as an applied ethics 3-7. It does not do so because, apparently and increasingly, the field of reflection and contemplation is growing at the expense of a decline in acion, pracice and intervenion.
This does not mean, however, that there has been no attempt to answer such criticism. The objecive of this aricle is precisely to categorize this concern, by describing in operaive terms the three pracical approaches born from the same, but in an innovaive manner, and not by the division described and already reported in other studies 8. As such, the
study does not adopt a descripive, philosophical or historical perspecive (already suiciently reported in literature), but adopts a practical position, idenifying the operaive proposiions that each approach defends, or in other words, the path that each proposes towards the making of moral decisions or acions.
The aricle, divided into ive parts, aims to present this perspecive, and in doing so take a irst step towards the development of complementary approaches that respond, essenially, to visions of bioethics emerging from peripheral countries.
The four principles
Emerging from the fields of biomedicine and biotechnology in the USA, the four principles (autonomy, non-maleficence, beneficence and jusice) – were created in 1979 by two Georgetown University professors, Tom Beauchamp and James Childress 1, ater several scandals in that country 9. Their main antecedent was the Belmont Report 10.
The authors argue that the methodology or operaionality of this approach occurs through the translaion of the principles into speciic guidelines that are applicable to day-to-day situaions, staing that two procedures are required for this process of translaion to occur: “speciicaion” and “weighing” 11.
Speciicaion basically consists of a process of deliberation in which the stated principles are applied to specific cases, and involves the consideraion that the principles have a prima facie obligaion, that is, they oblige absolutely only “at irst sight”. This prima facie obligaion connects with the second procedure: “weighing”, which means that this absolute obligaion only remains binding unil there is a conlict between the four principles, and prioriizes some obligaions - which were absolute “at irst sight” - over others 12.
To these two procedures are added others, namely “mediation” and “negotiation”, involving the permissiveness, correctness and incorrectness of moral acts, thus producing the aforementioned deliberation, which can be defined as a process in which decisions are made based on the rational plausibility of the arguments. With regards to such rationality, it is important to point out that this theory is centered on what the authors call secular human ethical rationality, or the common morality.
To explore how this operationalization – mediated by speciicaion, weighing, mediaion and negoiaion, and based on raional deliberaion – occurs, it is important to discuss each of the principles proposed by Beauchamp and Childress.
Autonomy
For Beauchamp and Childress 13, autonomy only occurs when there is intenionality, knowledge and the absence of external inluences. It is perhaps the principle that best represents operaionalizaion through its basic paradigm: informed and voluntary consent.
It must irst be said that the authors deine consent as the autonomous authorizaion of the individual to paricipate in medical intervenion or research 13 and highlight the following basic components of this instrument: the iniial elements (prerequisites), informaive elements, and elements of consent 14.
It is also important to state that the procedures of weighing, mediaion, negoiaion and speciicaion are of paramount importance in the case of autonomy and, consequently, of informed consent, especially when dealing with the autonomy of children, adolescents, psychiatric paients or humans in an unconsciousness state.
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The authors also clearly deine the informaion that should be included in informed consent. They say that it must involve facts or descripions that paients consider important when acceping or otherwise the intervention or procedure in which they are invited to paricipate, as well as informaion related to the recommendaions of the health professional, the objecive of consent, its nature and limits 15.
Non-maleicence
By non-maleicence Beauchamp and Childress mean consciously refraining from harm, and explain that this principle has to do with issues related to quality of life, non-discriminaion on the basis of race or gender; and the premise that morality is not only based on responsibiliies, but also on harm caused by indirect damages. With non-maleicence, the authors use the same procedures as were used with autonomy, and propose three guidelines of acion that, according to their understanding, allow doctors and researchers to resolve their ethical dilemmas.
The irst of these guidelines is a rule regarding non-treatment, or in other words, not iniiaing or withdrawing treatment. The explanaion for this rule lies in the premise that it is generally more diicult, as it has greater consequences, to withdraw a treatment than to iniiate it, as well as in the fact that it is morally worse not to propose or not to allow the start of a treatment, than not to atempt it.
This irst guideline, then, seeks to provide tools that allow the physician to: jusify the informaion – type and quanity – that they supply to the paient; support their decisions regarding the iniiaion or withdrawal of treatment; and, inally, invite a paient to undergo experimental treatments of which the beneits – and the damages – are not yet known.
The second guideline involves a rule to disinguish between ordinary treatments – also described by the authors as obligatory – and extraordinary treatments – also known as opional – with the purpose of carefully determining if they are beneicial or not for the paient, taking into account the risks and beneits to which he or she will be exposed. This second guideline assists the physician, for example, in situaions in which they must deal with the prolongaion or otherwise of life in terminal illnesses.
Finally, the third guideline seeks to difereniate between life-sustaining techniques and purely medical techniques. The irst, which authors categorize as “non-medical”, includes parenteral nutriion and hydraion, while the later, considered as medical, includes life support treatments such as respirators and dialysis equipment.
Beneicence
Related to the above principle, beneicence is understood by Beauchamp and Childress as the positive obligation that all human beings must act for the beneit of others. Also relaing to non-maleficence, beneficence depends entirely on autonomy, as according to the authors, an acion can only be judged as beneicial when the subject of the acion agrees to consider it as such.
The authors subdivide the operaionalizaion of this principle into posiive beneicence, on the one hand, and the uility principle, on the other. The idea is to clarify that, although the principle obliges acion for the beneit of others, this beneit must be contextualized – which is where the uility comes in – in relaion to the potenial risks and contraindicaions that could be generated. It should be emphasized that the authors difereniate between uility and uilitarianism, clarifying that autonomy is essential and should always be respected, above cost-beneit, cost-efeciveness, or risk-beneit analysis.
Jusice
The conception of the authors regarding jusice is that of a distribuive jusice, in which scarce therapeuic resources are expected to be distributed according to a uilitarian and egalitarian logic. From a uilitarian perspecive, Beauchamp and Childress defend social eiciency and the maximum beneit for the paient, while from an egalitarian perspecive, the merits of each person alongside the equality of opportuniies are ensured, so that one who is disadvantaged in comparison to another has an equal chance of access.
The authors have not ofered a theory of operaionalizaion for this principle, meaning that it remains only in abstract and general postulates, and escapes the procedures of specification, weighting, mediation and negotiation. Instead they suggest only chance as a way to operaionalize
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jusice – to which the other three principles have tried to respond.
Casuistry
Casuistry does not defend reasoning based on principles, except in cases which in some manner resort to the general principles that have been previously discussed in their pariculariies. Its origin is medieval and it was used by orders of Jesuits seeking a way to jusify certain moral decisions 16.
According to Miller, scholars who advocate casuistry argue that it is intended to help in situations where rules become confused, and in which moral conlicts are not easily resolved, producing responses that lead to moral guilt 17.
This approach proposes to examine speciic cases to extract theoretical rules which can be applied to other similar situaions. For Jonsen and Toulim 18, the casuisic method can be summarized in six components: paradigms and analogies, maxims (principles, intuiions), circumstances, degrees of probability, arguments, and resoluion.
Casuistry ofers alternaives to so-called moral absoluisms, which is important in the relecion and decision-making of thinkers who advocate a less abstract view of the moral world. Hence, those who employ casuistry the most are those who follow the paths of uilitarianism or pragmaism.
For Kirk, reasoning that describes itself as casuisic must bring together certain atributes. Iniially, the central issue must be related to the intenion to solve a speciic case or problem, rather than an abstract, conceptual or doctrinal dilemma 19.
It can be seen why this is the method par excellence followed by the so-called “three pracical ethics” – business ethics, environmental ethics and bioethics. To clarify a little the operationalization process proposed by casuistry, we can group the necessary steps to achieve moral reasoning into stages.
First stage
The irst stage involves exhausively describing the situaion to be analyzed. Casuistry emphasizes that such exhausive descripion is, perhaps, the most important part of the procedure proposed, as on it will depend the appropriate choice of the paradigmaic case to be taken as a reference or, if such a case is
not found, the proper ideniicaion of the situaion under analysis as unprecedented – and its subsequent inclusion within the matrix of paradigmaic cases -.
Thus, the description implies a careful examination of the situation, including the ideniicaion of the central actors, the interests at stake, proposals and insituional – of social insituions such as the family, the hospital, health providers, and government, among others – and personal moives.
Second stage
The second step relates to choosing a “paradigmaic”, “precedent” or “pure” case - which has already been analyzed - the characteristics of which are suiciently similar to the situaion being studied. This choice of paradigmaic cases is understood as the choice of a blueprint model or case - on which the majority agrees - from which the situaion under study can be analyzed. It is assumed that a large base of paradigmaic cases guarantees suitable analysis and decision making, which is why the work of “rescuing” this type of case is central.
These cases exemplify a general ethical dictum – of general moral judgment – by which, as already menioned, casuistry relies on abstract principles to choose, at this stage, the paradigmaic cases that will support its analysis. This is important, as those who use this approach argue that although they use cases and dwell on the pariculariies of each situaion, they do not fall into an extreme “paricularism” that lacks general principles or moral norms.
Before proceeding with the next stage, it is essenial, however, to point out that those who defend casuistry clarify that at this point, when choosing the paradigmaic case, it is also possible that no “pure” cases can be adapted to the situaion studied, a hypothesis against which independent analysis should be used, more based on general principles than on previous cases.
Third stage
The authors airm that the contextualizaion of the situaion under analysis within the paradigmaic case chosen is essential as it grants ethical certainty and jusiicaion to the casuisic analysis. Furthermore, contextualizaion provides appropriate frameworks to bring discursive coherence to the situaions analyzed, giving ethical plausibility to the decisions that result from the use of casuistry 20.
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In addiion to the above, contextualizaion provides the opportunity to consider different pracical issues, which in other approaches could not be addressed simultaneously due to being mutually exclusive or compeing with or annulling each other. This is especially useful if one considers that the situaions that bioethics studies are usually mulifactorial, complex and conlicing.
Another useful feature of contextualizaion is to provide a staring point to begin deliberaions, which will result in making a decision regarding the situaion being analyzed. In using the paradigm, then, an atempt is made to ind principles or rules that help to solve the paradigmaic case, and that can help with the situaion addressed 21.
Fourth stage
This is the ime to consider the elaboraion of analogies that jusify the decisions that will be made, taking into account the contextualizaion, choice and descripion established. We must start by saying that it is this point which, in the opinion of some authors 22, truly difereniates the theory of the
four principles from casuistry and, therefore, is the core of the casuisic approach.
It does so because the argumentaive strength of casuistry lies precisely in the analogies that can be created from its procedures. Addiionally, the usefulness of this approach lies in the comparisons that make it possible to evaluate, or even beter, guarantee the validity of such comparisons. This is of great importance, for as Calkins says all moral reasoning rests, in some sense, on analogies 23.
Coninuing with the subject of analogies, it is important to say that just as paradigmaic cases provide ethical certainty and jusiicaion, analogies from paradigmatic cases to “less paradigmatic” cases transfer such justification to the latter. Analogies also ensure that the decisions taken are not decontextualized and, therefore, endow them with legiimacy. It is clear from this, once again, why analogy plays a central role in the concepion of the casuisic approach. This is what Ruyter argues when recognizing that analogies are powerful tools for defending or condemning moral pracices 24.
Fith stage
The ith stage, or decision-making regarding moral action, involves a review of the correct
characterizaion of the situaion analyzed, of the appropriate ideniicaion of the paradigmaic case to be used, and of the consistent argumentaion - based on analogies - for the taking of moral acion.
It can be seen in this last stage, then, that casuistry is an attempt to offer an eminently pracical approach to moral reasoning which, not being exclusively based on abstract principles or rules, turns to paricular cases for the resoluion of moral dilemmas and of circumstances that are conlicing to those to whom they are exposed and deal, in the case of bioethics, with situaions related to biomedicine and biotechnology.
It is also evident that the situaions it seeks to respond to are those presented in the doctor-paient or the researcher-research paricipant relaionships, because, like the theory of the four principles, it emerged from such areas. Casuistry is the answer of philosophers to moral problems arising in the medical ield.
Narraive bioethics
Narraive bioethics is deined as “narraive ethics related to medicine”, but also as “the expression of a hermeneuic approach to applied ethics, speciically in biomedicine” and as a peculiar
type of bioethics with a narraive dimension that goes beyond the usual limits of clinical bioethics, to connect with other dimensions of the medical humaniies, philosophy, ethics and literature 25.
It is seen, then, that from its very concepion – by emphasizing that it is a hermeneuic approach to bioethics - narraive bioethics is aimed at acion. Various scholars 26-29 have explained this, for they use narration, in a hermeneutical, deliberative, historical and dialecical way, for the understanding of - and the subsequent making of decisions about - problemaic and conlicive situaions that demand a speciic aitude on the part of the physician.
Having established this conceptual precision, it is ime, as with the other two previous approaches, to highlight the procedural particularities of narraive bioethics. To this end, what is considered the most important book on the subject will be used to adopt a pracical proposal in this respect, since, as we have seen, conceptual and theoreical revisions are common, but pracical approximaions - such as those presented by the book - are scarce.
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The book in question is “The Fiction of Bioethics” by Tod Chambers 30, the richness of which, besides giving an operaional and complex proposal of the narraive 31 absorbs muliple perspecives, as the author himself accepts. Chambers proposes the following as minimum points for the operaionalizaion of narraive ethics - as he calls it - and therefore, for moral decision making and acions when dealing with complex situaions. It should be clariied, before considering these, that the author starts from the fact that these complex situaions are cases in themselves, so that the basis of the narrative approach he defends – as do other authors 25 - lies in casuistry.
First point
The first point is the identification of the interpretaive stages of the narraive: recogniion, formulaion, interpretaion and validaion, through the collecion of data from each medical case in the light of convenions and tools typically atributed to narraion. Early on, Chambers clariies that his staring point is cases, though viewed in a diferent way, and which he calls “clinical case histories”. He argues that this is his staring point because these histories are today the central point of medical discourse when it comes to making moral decisions.
The author also asserts that, since the cases consitute, in themselves, a narraive genre, it is legiimate - and obligatory - to use narraive tools and convenions to enrich the casuisic analysis. When he speaks of these tools, he speciically refers to narraive convenions such as: characterizaion, plot, authorship, reading posiion, among others, which he defends as absolutely necessary to carry out a serious casuisic analysis, leading to plausible moral acions.
Chambers is especially concerned with highlighing the importance of studying the point of view of the storyteller, that is, revealing the authorship. He explains that this is important, as such authorship is of major signiicance in the analysis of moral dilemmas, because the reader of the case histories is immediately afected by the voice that is telling the story.
Second point
The second is the analysis of the “level of detachment” that the author and the reader of the text have regarding the case that is being narrated.
At this point, Chambers invites us to analyze what he calls the subjects of “authorship” or “readership” - also called “narrateeship” – as he considers the style of wriing - and its consequent readability - to be crucial in the development and understanding of a medical case. At this point, it is a quesion of observing how the medical case is being described in terms of authorship, such as whether the third person voice is being used to narrate, or if the reader is directly appealed to in the analysis of a bioethical dilemma.
It is useful to note that Chambers gives diferent names to the diferent kinds of authorship - naming them, for example, as “biological”, “academic”, “philosophical”, “casuisic”, “implied” - in order to illustrate the speciic characterisics that each one implies. In the case of the philosophical, mediated by the third person, there is a dramaizaion of the situaion narrated, while in the case of “casuisic”, the diametrically opposed efect occurs: there is a de-dramaizaion of the events narrated.
Finally on this point, according to the author, relecion on the level of distancing between author and reader is central to the discipline of medical ethics as it allows us to understand the associaion between the author and the diferent levels of the narraion. This translates into the suggesion that by relecing on the kind of authorship presented, one might beter understand the moral judgment that lies behind the reported situations and, therefore, have a beter prior analysis for future decision making.
Third point
The third point consists of the discussion of the chronotope, in other words, the place and ime in which the narrated events occur. It implies the observaion of ime and place as an indivisible unit and the producer of moral acions and decisions. Turning to the words of renowned author Mikhail Bakhtin, Chambers emphasizes the importance of analyzing the management of ime and place in the histories presented in medical cases. In this sense, the author highlights the need to idenify the complex - or, on the contrary, reducionist - character of the world presented within those histories, in spaial and temporal terms.
Over time, however, Chambers introduces an interesting concept that has to do not only
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with the description of the time in which the case is presented, but with the aspects of acceleration and deceleration of the narrative. In this respect, the author identifies at least four types of time, which differ in the way in which they are used to tell a story: ellipsis, when there is no mention of time in the history; summary, when time in history is contracted, giving the impression that all events have occurred almost simultaneously; scene, when time is marked sequentially – the best example of which is seen in stories that include dialogues; and stretch, when the time is dynamic, in a process that is not necessarily sequential.
Fourth point
The fourth point is connected to the examinaion of the opening and the closing of the histories, in order to understand the impact these have on the data presented. In total relaion to the previous point, Chambers proposes relecing not only on the descripion and use of ime in cases related in bioethics, but also on what he calls temporal “disrupions”, that is, the beginning and end of the stories being told. The importance of these disrupions is so great that the author compares them to the existence of diferent narraive genres, because according to his understanding, they let us glimpse a certain worldview.
Continuing with this line of thinking, Chambers argues that the type of beginning of a story can make the reader expect, with a greater or lower degree of anxiety, a transgression during the narraive, or anicipate the occurrence of a paricular event. He exempliies this point with police novels or works of terror, and argues that the beginnings and closures of medical cases that analyze bioethics typically lead the reader to expect a transgression to occur.
To complement this idea, Chambers asserts that bioethics case histories share a well-defined type of beginning and end. Regarding the former, Chambers argues that it is usually two sentences in which the positions of the doctor and the patient regarding the dilemma they are facing and the expectations they both have are made relatively clear. In terms of the latter, the author highlights three characteristics: the ending generally features a question or a call to action, and is directed at the reader.
Fith point
The ith, and last, point discussed by the author is related to the study of cases from the perspecive of feminist theory, which includes both the analysis of gender as a consituive part of the history, and a relecion on the diferences between female and male wriing styles.
Based on the quesion of whether it is possible to discuss a gender-related manner of telling stories, Chambers points out that it is important to relect on the masculine and feminine roles present in the stories, as they bring with them implicit cultural codes that necessarily impact on the moral acions and the decision making that the narraive induces, as described in the previous stages.
Considering gender, according to the author, is equivalent to unveiling the true character, origin and purpose of the codes described and, therefore, of the aitudes, acions and decisions that have been naturalized by the force of customs, power or ime. In other words, Chambers argues that a gender-mediated reading of the cases reported in the bioethical narraive may lead to a more criical view of the data discussed in the irst stage of this secion.
There is, however, a fundamental point that Chambers emphasizes, and which is repeated here, ater having been touched on in the third point: the importance of social jusice in the methodology of narraive bioethics. For the author, the relecion of the role of gender in the narrated history also opens the door to an encounter with social jusice, which has been forgoten in the area of bioethics. The next part of this aricle will develop the argument related to social jusice in narraive bioethics.
Discussion
The three approaches for developing a pracical bioethics emerged from central countries, and correspond to a vision of bioethics that deines the ield as exclusively related to medicine and biotechnology. All three also idenify the importance of making bioethics a concrete instrument for confronting dilemmas and moral conflicts. In this sense, aware of the existence of robust and abundant theoreical development, they are more concerned with providing the discipline with steps, stages and techniques to be implemented.
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In the midst of these steps, stages and techniques, the tools ofered by the narraive have been especially relevant, as they have allowed ideas, such as principles, and exercises, such as case studies, to be beter interpreted, by proposing a process of relecion and interpretaion of the same. In this sense, the narraive has ofered a hermeneuic and interpretaive look 32 at approaches
that on many occasions did not quesion or think about themselves, allowing beter informed and contextualized decision making in the clinical environment 33.
It is important at this point to add that the narrative begins from the recognition of the importance of casuistry, which is part of its construcion. This is evident when the proponents of the narraive explicitly accept that the exercise of narraion is born from the understanding of medical cases as stories and when narraive elements are used by them to enrich those stories. It is clear, therefore, that more than a paradigmaic rupture, these thinkers propose to build on what has been constructed, taking not only the cases as narraives, but the principles as support for the analyzes and moral judgments.
This construction on what has already been constructed is relevant, as it shows that the hermeneuic component that the narraive involves necessarily enriches the moral reasoning exercise that principialism and casuistry have proposed to do for decades. José Roque Junges 34, a Brazilian bioethicist, perceives that bioethics may have two strands, arguing that casuistry and principialism are two complementary faces of bioethics, and suggesting that hermeneutics is a necessary complement to avoiding ethical and cultural convenions or economic and poliical conservaism in issues related to health.
Notwithstanding the above, it is possible to see a subtle openness to other themes, moving from principialism, to casuistry and to narraive. Narraive, especially, opens up possibiliies not found in the other approaches to include the gender perspecive and the defense of social jusice and implement speciic steps to operaionalize bioethics. In this sense, the idea of bioethics that the narraive hopes to put into pracice could be open to themes other than the merely biomedical and biotechnological.
The relaionship between narraive, ethics, gender and social jusice is not unprecedented, and
there is already important literature on the subject. It is important to remember that this nascent relationship in bioethics, the fruit of narrative bioethics, has a consolidated antecedent, of which an important exponent is Martha Nussbaum, a recognized American philosopher who shows clearly how narraive can serve to address moral conlicts relaing to the inequality and poverty present in the world, essenially through what she describes as the moral imaginaion and the moral narraion 35.
Nussbaum has emphasized in several of her works 36 that narrative elements, sometimes generated by the Socraic method, can enrich moral judgment, producing in actors who make decisions emoions such as empathy and compassion. According to the author, these elements can lead to richer moral decisions, taking into consideration the different nuances that stories – in contrast to simple cases or reports - include, among others: seings, imes, characters, tradiions, feelings, values and principles.
A few more words should be devoted to the way in which, according to Nussbaum, it is possible to make moral decision-makers enrich their discussion and moral reasoning. In this regard, this author proposes the inclusion of literary texts 37, such as novels and poems, both during the academic study and training of these decision makers, as well as in discussions about the decision to be made. Nussbaum says that literature has the power to make human beings imagine realiies opposite to their own and, in doing so, to become more sensiive to the situaions of pain, fear or sadness that another human being may be going through 38.
This author shows, for example, in one of her most important works, how the narraion of a life history marked by poverty, inequality and injusice can lead to the creaion of an economic theory that produces moral decisions that create public policies that are more inclusive and fairer in health, economic and social issues. Nussbaum even observes that this is one of the few viable ways to counteract the economic perspecive that globalizaion defends, with its subsequent neoliberal policies generaing misery, inequality and death 39.
This is relevant because it shows that the narraive has the potenial, indeed, to be a vehicle that introduces social, health and environmental issues to bioethics, which is historically associated only with biomedical and biotechnological issues. And, furthermore, that this narraive responds equally well
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to the need to enrich analysis and moral reasoning in both epistemological and methodological terms.
Following this line of thinking, it may be that this narraive bioethics is the approach that best dialogues with the bioethics that emerged outside central countries, the majority of which lack, for the most part, pracical developments that support their theoreical foundaion. It could be that a narraive approach is the opportunity for these bioethics – which include Lain American bioethics 37,38 - to be made operaional and deiniive, complemening their already well-defended epistemological bases.
In this regard, it is worth recalling that the origin of the narraive in bioethics is Lain American, specifically through the work of Mainetti 40-43 in Argentina in the 1980s. This South American physician, a disciple of Paul Ricoeur – the father of hermeneuics – was a pioneer in introducing literary elements to bioethical analysis, emphasizing the importance of enriching a purely clinical moral analysis with the tools that literature and hermeneutics provide, among them, creativity, imaginaion and sensiivity. Certainly, this inding can be of great help in the development of a narraive pracice for bioethics from peripheral countries whose interests are more connected with social than strictly medical and biotechnology issues.
Final consideraions
It is important to note that, as described above, the three approaches analyzed here – the theory of the four principles, casuistry and narraive bioethics - have important similariies and even represent a “continuum”. Thus, the innovative narraive approach or that proposed by narraive ethics is evidently based on the study of cases, on the recogniion of the importance that this study has and, therefore, on casuistry. This, in turn, and as several of the authors who defend it seek to clarify, is closely related to the respect and acceptance of the validity of principles, and therefore, with principles such as those defended by the theory of the four principles.
From the previous observaion, the narraive approach must be effectively operationalized, proposing concrete ways that will, in fact, lead to the sensiizaion and generaion of emoions proposed by the authors. In other words, narraive bioethics must provide not only the important space for a reading (and re-reading) of the principles and cases reported by bioethics for decades, but also the tools that produce the aforemenioned sensiizaion. In this respect, the use of literature, by means of novels and poems, to name just a few literary genres, will be essenial. However, other arisic languages capable of generaing emoions, such as the empathy and compassion emphasized by authors who defend the narraive in ethics, should not be excluded.
It is also important to note that all the approaches analyzed respond to a concepion of bioethics in the medical and biotechnological area. However, in the narraive approach there could be an opening for the inclusion of other issues, such as those defended by bioethics that did not emerge within the central countries - such as Lain American bioethics - which, in general, lack pracical operaional developments. Thus, a next step will be to critically review these three procedural approaches in order to propose, in the future, a pracical perspecive that applies to the broad vision of bioethics defended by Poter and taken up by the bioethics of peripheral countries.
This point is fundamental as it means the implementaion of the pracical approach that has been sought by these non-central bioethics. In other words, what is proposed here is that narraive bioethics can ofer answers to the recurrent criicism that peripheral bioethics do not have enough methodological and procedural elements to develop their premises and conceptual bases. In this sense, the intriguing progress made by Martha Nussbaum, in relaing ethics, decisions and moral reasoning, social causes, inequity, injustice, narrative and imaginaion, is central, as it demonstrates that it is possible to use narraive from a procedural point of view to produce beter informed and more profound moral decisions. This is the hope, and also the challenge for future studies.
This aricle forms part of a doctoral research study in the Postgraduate Program in Bioethics of the Universidad de Brasilia (the University of Brasilia) (UnB). The author would like to thank Prof. Dr. Jan Solbakk for his wonderful guidance during the creaion of this study.
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Recebido: 30.8.2016 Revisado: 28.3.2017 Aprovado: 30.3.2017
